Approach to the Patient With Hepatitis C and Hepatitis B Coinfection?

January 10, 2007

Ask the Experts about Liver Disease

From Medscape Gastroenterology

Question

What is the recommended approach to medical management in patients

coinfected with hepatitis C and hepatitis B? What is the goal of treatment

in this setting?

Response from Bernstein, MD

Chief, Digestive Disease Institute, North Shore University Hospital-Long

Island Jewish Medical Center, Manhasset, New York; Associate Professor of

Medicine, New York University School of Medicine, New York, NY

Hepatitis B and hepatitis C are common infections and therefore it is not

uncommon to see patients coinfected with both of these viruses. The

combination of both infections appears to lead to an increased risk for

liver damage as well as an increased risk for the development of

hepatocellular carcinoma. The treatment of hepatitis B and hepatitis C

coinfection is complicated by the lack of an approved recommended therapy

for this combination of infection. Usually, in the evaluation of these

patients, 1 of the 2 viruses will predominate; this can generally be

determined by the level of serum hepatitis B virus (HBV) DNA or serum

hepatitis C virus (HCV) RNA. Studies have shown that both viruses can

inhibit the replication of the other virus. Of note, in most cases, HCV

predominates over HBV.

The approach to therapy for patients coinfected with hepatitis B and

hepatitis C involves treating the predominant infection. If hepatitis C is

predominant, then treatment should be initiated with a combination of

pegylated interferon and ribavirin. Pegylated interferon may have a

suppressive effect on HBV, as pegylated interferon is approved for the

treatment of hepatitis B infection, although it has not been shown to date

to be effective in the treatment of HBV/HCV coinfection. The goal of therapy

in hepatitis C-predominant disease is to eradicate HCV and have a sustained

viral response.

If hepatitis B is the predominant virus, then treatment should be initiated

for HBV infection. Currently approved therapies for hepatitis B infection

include interferon, pegylated interferon, lamivudine, adefovir, entecavir,

and telbivudine. Care should be taken when initiating these regimens because

interferons should not be used in patients with hepatitis B-related

cirrhosis and lamivudine should not be used at all secondary to concerns

regarding the development of antiviral mutations. Once treatment is

initiated, the goal of therapy is similar to that for the monoinfected

hepatitis B patient: The goal of therapy in patients infected with wild-type

virus is e antigen seroconversion, whereas the goal of therapy in patients

infected with precore mutant strains is prolonged viral suppression.

Posted 01/02/2007

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Suggested Readings

Crockett SD, Keefe EB. Natural history and treatment of hepatitis B virus

and hepatitis C virus coinfection. Ann Clin Microbiol Antimicrob. 2005;4:13.

Dai CY, Yu ML, Chuang WL, et al. Influence of hepatitis C virus on the

profiles of patients with chronic hepatitis B virus infection. J

Gastroenterol Hepatol. 2001;16:636-640.

Zarski JP, Bohn B, Bastie A, et al. Characteristics of patients with dual

infection by hepatitis B and C viruses. J Hepatol. 1998;28:27-33.

http://www.medscape.com/viewarticle/549739?src=mp

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January 10, 2007